Highland Rehabilitation & Health Care Center

Inspectors wroteBased on interview and record review, the facility failed to develop and implemented an effective discharge planning process for two sampled residents (Resident #1 and Resident #2) out of 13 sampled residents. The facility census was 122 residents. On 7/17/26, the Administrator was notified of the past noncompliance which took place on 6/3/26 and 6/15/26. Discharge planning documentation discrepancies were discovered from the appeals. Education to address the problem was provided to facility staff, including the Administrator, the Director of Nursing (DON) and Social Services Director on 6/16/26 and problems with discharge planning were identified with Resident #1 and Resident #2. The deficiency was corrected on 6/16/26. [...]

Inspectors wroteBased observation, interview and record review, the facility failed to prevent resident abuse when on 5/27/26 Resident #1 lunged at and grabbed Resident #2, the two residents wrestled to the floor hitting and scratching each other, out of three sampled residents. The facility census was 127 residents. The Administrator was notified on 6/4/26 of the past noncompliance which began on 5/27/26. The facility revised the resident smoking policy and the staff assignment sheets and completed education for licensed nurses and Certified Nursing Assistants (CNAs) regarding the revised resident smoking policy and assignment sheets. Education was completed with all staff on resident-to-resident abuse. The deficiency was corrected on 5/28/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify Guardian A using the agreed upon protocol for one sampled resident (Resident #1) who had a change in condition out of 19 sampled residents. The facility census was 128 residents.1. Review of Resident #1's admission Record showed he/she admitted to the facility with a diagnosis of schizoaffective disorder (a mental health condition that includes features of both schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and a mood disorder), bipolar type (a mood disorder that can cause intense mood swings). NOTE: The admission Record showed the emergency after-hours phone number of Guardian A. Review of the resident's Behavior Note dated 5/4/26 at 5:51 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident #4) was free from abuse when Resident #3 punched him/her multiple times resulting in Resident #3 fracturing his/her hand and Resident #4 scared and praying for a reason to live out of 19 residents sampled. The facility census was 127 residents. The facility staff was notified on 3/18/26 of Past Non-Compliance which occurred on 3/10/26. Facility investigation, safety measures to mitigate further occurrence, staff in-services and education was completed. The deficiencies was corrected 3/18/26. Review of the facility's Abuse, prohibition, and intervention policy, dated March 2025, showed:-Each resident had the right to be free from abuse.-The definition of abuse was the willful infliction of injury, with resulting physical harm, pain, or mental anguish. 1. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure one sampled resident (Resident #6) out of seven sampled residents, was free from physical abuse. On 11/21/25, Resident #5 kicked and punched Resident #6 in the left jaw resulting in a fracture of the jaw. The facility census was 125 residents. Review of the facility Abuse, Prevention and Prohibition Policy dated 11/2025 showed: -Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. -Residents must not be subjected to abuse by anyone, including, but not limited to other residents. -The facility prohibited abuse of residents. -The resident must not be subjected to abuse by anyone. -Resident to resident abuse includes the term willful, which means that the individual's action was deliberate, regardless of whether the individual intended to inflict injury or harm. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to provide adequate care and supervision to prevent accidents for one sampled resident (Resident #2) out of seven sampled residents, when on 11/12/25 CNA A failed to position the resident properly in the bed and then turned away from the resident which resulted in a fall from the bed onto the floor with bruising and abrasions. The facility had further failed to transfer the resident with a Hoyer lift (mechanical transfer) and two staff per policy. The facility census was 125 residents. Review of the facility Safe Lifting and Movement of Residents Policy, dated December 2024, showed: -Resident safety, dignity, comfort and medical condition will be incorporated into goals and decision regarding the safe lifting and mobbing of residents. -Manual lifting of resident shall be eliminated when feasible. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision of residents to prevent accidents. Facility staff failed to develop and implement interventions for one resident (Resident #8) who was at risk of elopement and who made statements regarding his/her intent to leave. The facility failed to ensure adequate supervision of residents during the smoke break, resulting in the resident not returning into the building at the end of the break. The resident climbed a fence and pushed him/herself off the ledge from the second floor smoke deck and broke his/her left tibia with a compound fracture which required immediate surgery and will require a second surgery. The facility census was 136. On 3/27/25 the Administrator and Director of Nursing (DON) were notified of past non-compliance Immediate Jeopardy (IJ) which occurred on 3/24/25. [...]

Inspectors wroteBased on observations, interviews, and facility document and policy review, the facility failed to ensure food was prepared, stored, and served in accordance with professional standards for food safety as evidenced by the following: 1. Staff were not wearing beard guards to cover facial hair when in food preparation areas; 2. Food items, including sausage patties and chocolate chips, were not stored in closed containers; 3. Open food items, including preboiled eggs, diced pineapple, honey, and sausage gravy, were not dated; and 4. Residents' personal food items stored by the facility were not labeled with a resident's name and date and were not discarded when indicated. These failures had the potential to affect all 129 residents receiving meals from the dietary department at the time of the survey.

Inspectors wroteBased on observation, interview, record review, facility document and policy review, and review of the Centers for Disease Control and Prevention (CDC) enhanced barrier precaution (EBP) signage, the facility failed to provide care in accordance with infection control standards for 2 (Resident #336 and Resident #103) of 9 residents reviewed for the infection control task. Specifically, the facility failed to ensure staff implemented enhanced barrier precautions (EBP), including appropriate hand hygiene and personal protective equipment (PPE) use, when providing care to Resident #336 and Resident #103. In addition, the facility failed to ensure Resident #336's indwelling urinary catheter drainage bag and tubing were not on the floor.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide a privacy cover for a urinary catheter drainage bag for 1 (Resident #63) of 1 resident reviewed for dignity.

Inspectors wroteBased on observation, interview, record review, and facility document review, the facility failed to ensure resident room floors and equipment were cleaned and maintained for 1 (Resident #103) of 4 residents reviewed for environmental concerns. Specifically, the facility failed to ensure tube feeding formula was cleaned off the resident's tube feeding pump, pole, and floor.

Inspectors wroteBased on observation, record review, facility document and policy review, and interview, the facility failed to ensure facility staff honored a resident's right to be free from a physical restraint that was not required to treat the resident's medical symptoms for 1 (Resident #386) of 3 residents reviewed for abuse. Specifically, a facility staff member picked up and carried Resident #386 off the smoking patio and back into the facility, thereby restricting the resident's freedom of movement when the resident attempted to grab another resident's cigarette.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to thoroughly investigate 1 of 3 entity self-reported incidents reviewed. Specifically, the facility failed to thoroughly investigate an incident involving a missing resident (Resident #96).

Inspectors wroteBased on interview and record review, the facility failed to ensure Level I Preadmission Screening and Resident Reviews (PASRRs) were completed when 2 (Resident #45 and Resident #23) of 4 residents reviewed for PASRR requirements were diagnosed with new mental disorders.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's mental and psychosocial needs for 1 (Resident #73) of 2 residents reviewed for mood/behavior.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to provide adequate supervision for 1 (Resident #96) of 6 residents reviewed for accidents.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to provide physician-ordered medications to meet the needs of 1 (Resident #339) of 1 resident reviewed for significant medication errors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bathing was completed and staff used a specialized shower chair; and to ensure the care plan was updated for the need of a specialized shower chair for one sampled resident (Resident #2) out of 5 sampled residents. The facility census was 136 residents. A policy for bathing or Activities of Daily Living (ADLs-grooming, bathing, hygiene) was requested and not receive at time of exit. 1. Review of Resident #2's admission Face Sheet showed he/she was admitted to the facility on [DATE] with diagnosis of Cerebral Palsy (CP, is a group of disorders that affect a person's ability to move and maintain balance and posture). Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 2/8/24, showed the resident: [...]

Inspectors wroteBased on interview and record review, the facility failed to arrange a safe and orderly discharge for one sampled resident (Resident #2) and failed to have a policy in place for the disposition of medication when transferring to another facility out of three sampled residents. The facility census was 121 residents. Review of the facility's Discharge Summary and Plan revised 11/2022 showed the discharge plan will include resident and family/caregiver education needs and will initiate or maintain collaboration between the nursing facility and other post-acute care providers to support resident transition. 1. Review of Resident #2''s Quarterly Minimum Data Set (MDS- a federally mandated assessment tool that facility's complete for care planning) dated 11/15/23 showed: -He/She was admitted to the facility on [DATE]. -He/She was cognitively intact. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide and/or failed to provide an accurate Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) for two sampled residents (Resident #107 and #181) out of three sampled residents who were discharged from Medicare part A services. The facility census was 125 residents. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09 showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) was issued when all covered Medicare services end for coverage reasons. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with a mental disorder diagnoses had a DA-124 Level I screen (used to evaluate for the presence of psychiatric conditions to determine if a preadmission screening/resident review (PASRR) level II screen was required) as required, for care planning for one sampled resident (Resident #10) out of 26 sampled residents. The facility census was 125 residents. A policy was requested and not received by the facility. 1. Review of Resident #10's admission Assessment showed he/she was admitted to the facility with the following diagnoses: -Paranoid Schizophrenia (characterized by predominantly positive symptoms of schizophrenia, including delusions and hallucinations. These debilitating symptoms blur the line between what is real and what isn't, making it difficult for the person to lead a typical life). [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the appropriate state-designated authority for a Level II Preadmission Screening and Resident Review (PASRR) to ensure residents with diagnoses of a mental disorder or intellectual disability had a DA-124 level I screen (used to evaluate for the presence of psychiatric conditions to determine if a preadmission screening/resident review (PASRR) level II screen was required) for one sampled resident (Resident #1) out of 26 sampled residents. The facility census was 125 residents. A PASRR policy was requested and not received by the facility. 1. Review of Resident #1's admission Record showed he/she had the following diagnoses: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure restorative services were provided per therapy recommendations to maintain, improve, or prevent decline in Range of Motion (ROM the range on which a joint can move) for one sampled resident (Resident #1) out of 26 sampled residents. The facility census was 125 residents. Record review of the facility's undated policy Restorative Nursing Policy and Procedure showed: -The facility provided restorative nursing to promote the residents' abilities and to adjust to living as independently and safely as possible. -Restorative therapy focuses on achieving and/or maintaining optimal, physical, mental, and the psychological function of the resident. -Any resident discharged from therapy should be assessed for the need of restorative therapy. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the physician ordered bolus feeding (Bolus feeding - a type of feeding method using a syringe to deliver formula) was administered accurately through the resident's Percutaneous Endoscopic Gastrostomy tube (PEG-tube - a tube that is placed into a patient's stomach as a means of feeding them when they are unable to eat), to administer water flushes (keeps tube clean and patient hydrated) per professional standards of practice prior to and after medication administration per the resident's PEG tube, to follow up with the physician related to new Registered Dietician (RD) recommendations, to provide/offer by mouth diet as ordered by physician and to follow physician orders for PEG tube site care on one sampled resident (Resident #34) out of 26 sampled resident's. The facility census was 125 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure intravenous (IV) services were provided consistently with professional standards of practice by failing to ensure staff obtained physician's orders for a Peripherally Inserted Central Catheter (PICC - a thin, soft, long tube that is inserted into a vein in an arm, leg or neck. The tip of the catheter is positioned in the superior vena cava, a large vein that carries blood into the heart) by not identifying PICC brand and number of lumens (the PICC splits into one, two, or three smaller tubes outside your body called lumens), assessing PICC insertion site, measuring and documenting the length of the PICC and left arm circumference and changing of needleless connectors during weekly dressing changes for one sampled resident (Resident #6) out of 26 sampled residents. The facility census was 125 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of waterborne pathogens (a bacterium, virus, or other microorganism that can cause disease), failed to have the hot water boilers set to a high enough temperature to prevent the growth of waterborne pathogens, and failed to provide documented assessments for such an outbreak, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents and staff who reside in, use, or work in the facility. The facility census was 121 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the ceiling tiles and the ceiling vents in the second and fourth floor dining room, free of a heavy dust buildup. This practice potentially affected at least 70 residents who used those dining rooms for eating and activities. The facility census was 121 residents. 1. Observation on 11/16/21 at 9:08 A.M. during breakfast and at 12:23 P.M., during lunch, showed a buildup of dust on the ceiling tiles and on the ceiling vents of the fourth floor dining room. 2. Observation on 11/17/21 at 11:39 A.M., showed a buildup of dust on the ceiling tiles and on the ceiling vents of the second floor dining room. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an emergency discharge letter was provided to the resident's court appointed legal guardian (someone who has the legal authority and responsibility to make decisions) and/or the resident's representatives with Durable [NAME] of Attorney (DPOA) (a person who has the legal authority and responsibility to make decisions for another person) for three closed record sampled residents (Resident #13, #55, and #56) and to ensure the Ombudsman (a person who investigates, reports on, and helps settle complaints) was notified for a resident discharge for one closed record sampled resident (Resident #13) out of three closed sampled residents. The facility census was 121 residents. Record review of the facility's guidance information for discharge requirements, undated, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post complete staffing information to include the facility name, the facility census, and the actual hours worked for Registered Nurses (RN's), Licensed Practical Nurses (LPN's), and Certified Nursing Assistants (CNA's)/Certified Medication Technicians (CMTs) directly responsible for resident care for each shift, in locations throughout the facility easily accessible for view by residents and the public. The facility census was 121 residents. Record review of the facility's Posting Direct Care Staffing Numbers policy, dated 2/2021 showed: -The facility will post the staffing on a daily basis at the beginning of each shift. -Each sheet will have a daily census listed. -Each of the following staff will be listed on the sheet: RN, LPN, and CNA, and their actual and total number of hours worked will be posted. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to do the following: maintain the nozzles of the automated dishwasher free of debris inside the nozzles; date a package of sliced cheese as to when it was opened; maintain the utensil storage containers free of debris; maintain three cutting boards free of numerous nicks and grooves and stains; maintain the floors under the dishwasher and the ice machine free of food debris; maintain the cover of the food processor in good repair; ensure three mittens were free of damaged areas; failed to ensure the third compartment of the three compartment sink had sanitizer to sanitize utensils; maintain the dietary food delivery carts in proper condition so that the doors to those containers closed. This practice potentially affected at least 116 residents who ate food from the kitchen. The facility census was 121 residents. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food in two refrigerators were labeled with a resident's name that the food belonged to. This practice potentially affected an unknown number of residents. The facility census was 121 residents. Record review of portions of the facility's policy entitled Foods Brought by Family/Visitors dated 1/2017, showed: -Family members should inform nursing staff of their desire to bring foods into the facility. -The dietitian or a Nurse Supervisor should assure that the food is not in conflict with the resident's prescribed diet plan. -Perishable foods must be stored in resealable containers with tightly fitting lids in the refrigerator. -Containers will be labeled with the resident's name and dated. 1. Observation on 11/18/21 at 12:42 P.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the outdoor dumpsters on the north side of the facility could be closed on 11/15/21 and 11/16/21. This practice affected the outdoor area on the north side of the facility. The facility census was 121 residents. 1. Observations on 11/15/21 at 1:21 P.M. and 3:58 P.M. and on 11/16/21 at 11:15 P.M., showed: -Two dumpsters open on the north side of facility. -One dumpster had a lid with 14 inch (in.) crack and the other dumpster had a damaged lid closing apparatus that could not be closed. During an interview on 11/16/21 at 11:15 A.M. Dietary Aide (DA) A said the dumpsters have been in that condition for at least two years. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the drainage area on the floor under and around dishwasher to ensure water drained properly from that area of the kitchen; failed to maintain the commode seats firmly attached to the commodes in resident rooms 218, 209, 206, and 205; failed to maintain a wooden bench used by residents in the second floor smoking area in good repair; and failed to maintain the door frame to the room labeled marketing storage, in good repair so it (the door frame) did not move, when the door was opened. This practice potentially affected at least 25 residents who resided on the second floor. The facility census was 121 residents. 1. Observations on 11/16/21 at 10:32 A.M., and at 1:43 P.M. showed a 43 inch (in.) long by 8 feet (ft.) wide section of standing water, was present under dishwasher. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure bed hold agreements were provided to the residents' representatives with Durable [NAME] of Attorney (DPOA) (a person who has the legal authority and responsibility to make decisions for another person) for two closed sampled residents (Resident #55 and #56) out of three sampled closed record residents. The facility census was 121 residents. Record review of the facility's Bed Hold Policy and Agreement Form, dated 2/2014, showed: -The bed hold agreement had to be obtained for each occurrence, hospital or therapeutic home leave. -When hospital or therapeutic home leave was reported on the facility's midnight census, the business office would notify the resident or responsible party to sign the bed hold agreement. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I and Level II were completed for one sampled resident (Resident #11) diagnosed with Developmental Disabilities out of 24 sampled residents. The facility census was 121 residents. Record review of https://health.mo.gov/seniors/nursinghomes/pasrr.php, updated 10/2021 showed: -The Pre-admission and Screening and Resident Review (PASRR) is a federally mandated screening process for individuals with serious mental illness and/or intellectual/developmental disability or related diagnosis who apply or reside in Medicaid certified beds in a nursing facility regardless of the source of payment. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident monthly pharmacy drug regimen recommendations were reviewed and acted upon by the physician and to ensure the pharmacy requests were completed for two sampled residents (Resident #125 and #57) out of 24 sampled residents. The facility census was 121 residents. Record review of the facility policy Medication Regimen Review, undated, showed: -A consultant pharmacist would review the resident's medications for irregularities. -If the consultant pharmacist identifies a concern or irregularities, a report would be given to the physician and Director of Nursing (DON). Record review of the facility policy Distribution of the Medication Regimen Review Report undated showed: -The report (of concerns/irregularities) would review the report and respond. [...]